The Skeleton in the Closet: Harvesting a Skeletonized IMA
DOI:
https://doi.org/10.1532/hsf.1867Abstract
There is a considerable amount of data that using more than one arterial graft provides a survival advantage for patients undergoing coronary bypass operations. The Society of Thoracic Surgeons has a set of official guidelines for the use of arterial grafts which include the following recommendations:
- Internal mammary arteries (IMA’s) should be used to bypass the left anterior descending (LAD) artery when bypass of the LAD is indicated.
- As an adjunct to left internal mammary artery (LIMA), a second arterial graft (right IMA or radial artery [RA]) should be considered in appropriate patients.
- Use of bilateral IMA’s (BIMA’s) should be considered in patients who do not have an excessive risk of sternal complications.
- To reduce the risk of sternal infection with bilateral IMA’s, skeletonized grafts should be considered, smoking cessation is recommended, glycemic control should be considered, and enhanced sternal stabilization may be considered.
- Use of arterial grafts should be a part of the discussion of the heart team in determining the optimal approach for each patient.
[Ann Thorac Surg 2016; 101: 801–9]
References
Aldea G, Bakaeen F, Pal J, et al. 2016. The Society of Thoracic Surgeons Clinical Practice Guidelines on Arterial Conduits for Coronary Artery Bypass Grafting. Ann Thorac Surg 101:801-9.
Ali E, Saso S, Ashrafian H, Athanasiou T. 2010. Does a skeletonized or pedicled left internal thoracic artery give the best graft patency? Interact Cardiovasc Thorac Surg 10:97-104.
Casha A, Gauci M, Yang L, Saleh M, Kay P, Cooper G. 2001. Fatigue testing median sternotomy closures. Eur J Cardiothorac Surg 19:249-53.
Dreifaldt M, Taggart D, Bodin L, Geijer H, Liden M, Souza D. 2017. Comparable mid- and long-term patency rates for skeletonized and non-skeletonized internal thoracic artery grafts: a prospective randomized trial. http://aats.org/aatsimis/AATS/Meetings/Active_Meetings/Centennial/Preliminary%20Program/Monday_Controversies_in_CABG_2017.aspx.
Flege J. 1987. Pericardial incision for IMA coronary bypass surgery. Ann Thorac Surg 44:424.
Gaudino M. 2015. The choice of conduits in coronary artery bypass surgery. J Am Coll Cardiol 66:1729-37.
LaPar D, Crosby I, Rich J, et al. 2015. Bilateral internal mammary artery use for coronary artery bypass remains underutilized: a propensity-matched multi-institutional analysis. Ann Thorac Surg 100:8-15.
Marasco S. 2016. Total arterial revascularization. Oper Tech Thorac Cardiovasc Surg 21:20-30.
Markman P, Rowland M, Leong J-Y, et al. 2010. Skeletonized internal thoracic artery harvesting reduces chest wall dysesthesia after coronary bypass surgery. J Thorac Cardiovasc Surg 139:674-9.
Owens WA, Gladstone DJ, Heylings DJ. 1994. Surgical anatomy of the phrenic nerve and internal mammary artery. Ann Thor Surg 58:843-4.
Taggart DP, Altman DG, Gray AM, et al, for the ART Investigators. 2016. Randomized trial of bilateral versus single internal-thoracic-artery grafts. N Engl J Med 375:2540-9.
Tector AJ, Amundsen S, Schmahl TM, Kress D, Peter M. 1994. Total revascularization with T grafts. Ann Thorac Surg 57:33-9.
